Information Collection

Complaints Related to Surprise Billing

IC 249022 under ICR 202108-0938-011 · OMB 0938-1406.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1406 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10779 Complaints Related to Surprise Billing	Form and Instruction
CMS-10779 Consumer Complaint Form - No Surprises Help Desk CMS-10779.Consumer Complaint Form_No Surprises Help Desk.docx	Form and Instruction
CMS-10779 Consumer Complaint Form - No Surprises Help Desk CMS-10779.Consumer Complaint Form_No Surprises Help Desk.docx	Form and Instruction
CMS-10779 Provider Complaint Form - No Surprises Help Desk CMS-10779.Provider Complaint Form_No Surprises Help Desk.docx	Form and Instruction
CMS-10779 Provider Complaint Form - No Surprises Help Desk CMS-10779.Provider Complaint Form_No Surprises Help Desk.docx	Form and Instruction

IC Title:

Complaints Related to Surprise Billing

Agency IC Tracking Number:

CCIIO - 10779

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 149.450 45 CFR 149.150

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10779	Consumer Complaint Form - No Surprises Help Desk	CMS-10779.Consumer Complaint Form_No Surprises Help Desk.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10779	Provider Complaint Form - No Surprises Help Desk	CMS-10779.Provider Complaint Form_No Surprises Help Desk.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	900	900
Annual IC Cost Burden (Dollars)	48,726	48,726

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.